Provider Demographics
NPI:1770069916
Name:GORDON, THOMAS (PHARM D)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 PARIS DR
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-1617
Mailing Address - Country:US
Mailing Address - Phone:618-610-2094
Mailing Address - Fax:
Practice Address - Street 1:12921 ENTERPRISE WAY
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-1206
Practice Address - Country:US
Practice Address - Phone:314-344-9604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.295883183500000X
MO2012026227183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist